advice to the profession prescribing: drugs associated

ADVICE TO THE PROFESSION

Prescribing: Drugs Associated with Substance Use Disorder or Substance-Related Harms

Last revised: Sep 2019, Sep 2018, Sep 2017, Jun 2017 Published: May 2017

Prescribing: Drugs Associated with Substance Use Disorder or Substance-

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Contents Scope .......................................................................................................................................................................... 1

Providing safe and compassionate care ..................................................................................................... 2

A Message about Opioids .......................................................................................................................... 3

Prescribing Requirements ........................................................................................................................... 4

Opioid Prescribing ......................................................................................................................................... 5

Benzodiazepine Prescribing ....................................................................................................................... 8

Example Scenarios................................................................................................................................................11

Resources ................................................................................................................................................................. 12

Appendix A: General Medications List ........................................................................................................ 16

Appendix B: Prescriber Checklist .................................................................................................................... 17

Scope The standard is deliberately broad for the purpose of patient safety: any medication linked to a substance use disorder or substance-related harm falls within its scope, which includes but is not limited to: opioids, benzodiazepines, sedatives and stimulants. Physicians are

The College of Physicians & Surgeons of Alberta (CPSA) provides advice to the profession to support physicians in implementing the CPSA Standards of Practice. This advice does not define a standard of practice, nor should it be interpreted as legal advice.

Advice to the Profession documents are dynamic and may be edited or updated for clarity at any time. Please refer back to these articles regularly to ensure you are aware of the most recent advice. Major changes will be communicated to our members; however, minor edits may only be noted within the documents.





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expected to exercise their judgment to determine when the standard applies, considering not only the medication, but also the clinical context in which the prescribing occurs. Refer to Appendix A: General Medications List.

Providing safe and compassionate care

There are important risks associated with prescribing opioids, benzodiazepines and other drugs associated with substance use disorders or substance-related harm. These risks include the development of a substance use disorder, poisoning or overdose, impaired function, associated injuries or the diversion of medication to others.

Physicians can take steps to mitigate these risks through sound clinical practice and relevant guidance, such as the Canadian Guideline for Opioids for Chronic Non-Cancer Pain (2017) from McMaster University and the similar guidelines from the U.S. Centers for Disease Control and Prevention.

When a medication with these risks is the best clinical option, the prescription should be for the lowest effective dose for a limited duration, in keeping with the natural history of the pathology resulting in pain. General guidelines suggest the ideal duration is three to seven days. Longer durations require clinical justification and specific monitoring of the circumstances.

Patients on long-term therapy with opioids, benzodiazepines or other drugs associated with substance-use disorders or substance-related harm have legitimate healthcare needs and a fundamental right to receive medical services, and physicians are ethically responsible to provide safe and compassionate care (see the Code of Ethics & Professionalism and Establishing the Physician-Patient Relationship standard of practice).

Primary prescribers have a responsibility to never abandon these patients, or abruptly cut off or threaten to cut off their medication.

Physicians must consider the potential risks of abrupt discontinuation, which can include the patient seeking drugs from the illicit market.

http://nationalpaincentre.mcmaster.ca/guidelines.html


https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm


http://www.cpsa.ca/standardspractice/code-of-ethics/

http://www.cpsa.ca/standardspractice/code-of-ethics/

http://www.cpsa.ca/standardspractice/establishing-physician-patient-relationship/





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When prescribing these medications, whether for very short term use or on a long-term basis, CPSA requires physicians to follow sound clinical practice, the core elements of which are:

discuss with the patient the risks, potential benefits and alternatives to the medication;

understand the individual health context, including co-morbid substance use disorder, risk factors for developing a substance use disorder, current prescribed medications by reviewing the Pharmaceutical Information Network (PIN)/Netcare or a valid alternative source, and identifying the use of other psychoactive drugs including alcohol and illegal drugs (confirming, when appropriate, by random urine drug screens);

document a patient-physician agreement that includes the goals of treatment (improved health and function) and the anticipated duration of the treatment; and

identify a justifiable indication for the drug treatment and, for longer-term treatment, provide periodic reassessment appropriate to the clinical circumstances, at least every three months (see Example Scenarios).

For a medical regulator to provide specific clinical guidance is rare, and means to send a larger message: safe and competent practice requires informed clinical decisions and coordination with other physicians, pharmacists, colleagues and the broader health system. We expect physicians to know what drugs their patients are taking, not just what they prescribe.

A MESSAGE ABOUT OPIOIDS Statistics show Canadians are prescribed more opioids than patients in most other countries; we also know historically more Albertans have been prescribed opioids than patients in other Canadian provinces. While recent Triplicate Prescription Program data shows opioids are being prescribed to fewer Albertans and in lower doses, what’s most important is making sure patients are being managed in a safe and compassionate way.

CPSA recognizes this is a very challenging area of practice and there is much uncertainty about how best to manage the complex clinical problems that often result in an opioid





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prescription. Regardless of the historical reasons for opioid overuse, physicians are ideally placed and ethically obligated to be part of the solution.

The evidence about opioid prescribing is evolving and the advice in this document reflects what we know today. As more evidence becomes available, we will update this advice to address some of the unique situations physicians may encounter.

PRESCRIBING REQUIREMENTS When prescribing drugs associated with substance use disorders or substance-related harm, physicians are required to review the patient’s medication history from PIN/Netcare:

before initiating a prescription;

before renewing a prescription, if the physician renewing is not the primary prescriber; and

at minimum, every three months when the prescription is for the long-term treatment of a patient.

CPSA acknowledges not all physicians can readily access PIN/Netcare. When access is unavailable, the physician must seek an alternative source for the patient’s medication profile that is independent of the patient and the patient’s family or friends. Acceptable alternative sources include a hospital or community pharmacist, or Triplicate Prescription Program (TPP) Alberta. TPP Alberta can be reached at 1-800-561-3899 ext. 4939 (in Canada) during regular office hours.

If the patient’s medication profile is not immediately accessible, the physicians may prescribe only the minimum amount of medication required until the information can be obtained.

Random urine drug testing (rUDT) and/or random pill counts should be done at least annually for all adult patients on long-term opioids, benzodiazepines, sedatives or stimulants.

http://www.cpsa.ca/tpp

http://www.cpsa.ca/tpp





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OPIOID PRESCRIBING

Initiating Opioid Therapy Before initiating opioid therapy for acute or chronic pain, the physician is expected to:

conduct a thorough assessment of the patient and ensure there is a clinically justifiable indication for opioid therapy;

discuss non-pharmacological and pharmacological options with the patient;

screen for potential for a substance use disorder;

check PIN/Netcare (or independent alternative source) to ensure the patient is not receiving prescriptions from other providers;

explain the risks and benefits of using an opioid medication for the diagnosed condition and ensure the patient has enough information to provide fully informed consent, and document this discussion in the patient’s record;

Refer to these guidelines:

Canadian Guideline for Opioids for Chronic Non-Cancer Pain (2017) – full guideline

Poster summary (English)

Poster summary (French)

CDC Guideline for Prescribing Opioids for Chronic Pain (U.S.) – full guideline

o Fact sheet

o Summary of recommendations

http://www.cpsa.ca/standardspractice/informed-consent/


http://www.cpsa.ca/standardspractice/patient-record-content/


http://www.cpsa.ca/wp-content/uploads/2017/05/CMA_Opioid-poster_EN_HR1.pdf

http://www.cpsa.ca/wp-content/uploads/2017/05/CMA_Opioid-poster_FR_HR2.pdf


https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf






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determine the nature of the patient’s work activities (if applicable), including any safety-sensitive work tasks, and counsel the patient regarding any workplace safety concerns related to the use of the medication(s) to be prescribed, including a discussion of work restrictions and limitations where a risk of impairment exists;

establish goals for treatment and set reasonable expectations with the patient, including that opioids can reduce but not eliminate pain;

prescribe the lowest effective dose as the risks of opioid use increase with higher doses: extreme caution is required when exceeding recommended guidelines;

NOT prescribe benzodiazepines, hypnotics and/or sedatives concomitantly with opioids;

identify other drug use by the patient, including alcohol, illegal drugs or diverted prescription drug use;

limit opioid prescriptions for acute pain to 3 to 7 days unless there is a justifiable indication for long-term opioid therapy, and document this justification in the patient record; and

for prescriptions of longer duration than 7 days, reassess the patient within 7 to 10 days.

Long-Term Opioid Therapy There are a number of conditions that cause pain and symptoms for which prescribed opioids might be considered within an encompassing program of pain modulation and pain coping strategies. Many referenced documents and standards refer to chronic, non-cancer pain.

CPSA encourages physicians to think about the underlying pathophysiology of pain when prescribing opioids. If a patient’s condition requires pain modulation beyond the acute phase, regardless of the underlying medical diagnosis, long-term opioid therapy warrants






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special considerations. Even in palliative care and end-of-life situations, care and skill must be exercised to ensure optimal outcomes for patients when prescribing opioids.

Physicians are expected to:

establish an opioid agreement with the patient;

offer a take-home naloxone prescription if the patient is at risk of respiratory depression as a consequence of receiving opioid medications, and document the offer;

order random urine drug testing (rUDT) and/or random pill counts at least annually if the patient is an adult;

counsel the patient appropriately regarding any ongoing workplace safety concerns related to the use of long-term opioid treatment, outlining work restrictions and limitations as needed

reassess the patient at least every three months to: o ensure the medication is providing effective pain relief and improved function, and

to assess any side- effects the patient may be experiencing;

o determine if the patient may be developing tolerance or an opioid use disorder;

o monitor closely for signs that: a) the patient is not taking the medication at the dose or by the route prescribed; and b) individuals other than the patient may be using the medication. These may include: the patient requests early refills, claims to lose the medication or provides

excuses for why additional medication is needed;

PIN/Netcare review reveals the patient is multi-doctoring to obtain additional medication;

http://www.cpsa.ca/wp-content/uploads/2016/08/Opioid-Treatment-Agreement.docx?x91570





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an alternate person requests the prescription from the physician;

another healthcare professional reports aberrant behavior, such as a pharmacist reporting the medication is being picked up by individuals other than the patient for no justifiable reason;

if the opioid dose exceeds current guidelines, carefully assess the patient to ensure the benefit is greater than the risk; a sound, clinically justifiable reason must be documented whenever exceeding the threshold; and

document patient-specific interactions and prescribing approach so colleagues who care for the patient in the primary physician’s absence can provide consistent care.

If the physician cannot clinically support continuation of the opioid, motivational interviewing strategies should be used to engage the patient in a slow taper. When tapering is challenging, physicians may wish to consider an opioid agonist therapy such as buprenorphine/naloxone. Physicians unfamiliar with the use of buprenorphine/naloxone should consider pursuing continuing medical education. Recommended courses are listed on the CPSA website.

BENZODIAZEPINE PRESCRIBING Benzodiazepines are highly addictive medications that can have adverse side-effects, particularly when used long term. Physicians treating patients with long-term benzodiazepine therapy should ensure the medication is indicated and the patient is on the lowest possible dose.

Initiating Benzodiazepine Therapy Before initiating benzodiazepine therapy, the physician should:

conduct a thorough assessment of the patient and ensure there is a clinically justifiable indication for benzodiazepine therapy;

discuss non-pharmacological and pharmacological options with the patient;

https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

http://cpsa.ca/wp-content/uploads/2015/07/buprenorphine_naloxone_CAMH2012.pdf?x91570

http://www.cpsa.ca/physician-prescribing-practices/buprenorphine-prescribing/

http://www.cpsa.ca/physician-prescribing-practices/methadone-program/





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screen for the patient’s potential for developing a substance use disorder;

check PIN/Netcare (or independent alternative source) to ensure the patient is not receiving prescriptions from other providers;

explain the risks and benefits of using a benzodiazepine for the diagnosed condition and ensure the patient has enough information to provide fully informed consent, and document the discussion in the patient’s record;

determine the nature of the patient’s work activities (if applicable), including any safety-sensitive work tasks, and counsel the patient regarding any workplace safety concerns related to the use of the medication(s) to be prescribed, including a discussion of work restrictions and limitations where a risk of impairment exists;

prescribe the lowest effective dose as the risks of benzodiazepine use increase with higher doses: extreme caution is required when exceeding recommended guidelines;

avoid prescribing benzodiazepines to elderly patients whenever possible;

NOT prescribe benzodiazepines concomitantly with opioids and/or sedatives;

limit benzodiazepine prescriptions to 3 to 7 days unless there is a justifiable indication for long-term benzodiazepine therapy, and document the justification in the patient record; and

for prescriptions of longer duration than 7 days, reassess the patient within 7 to 10 days.

Long-Term Benzodiazepine Therapy When prescribing long-term benzodiazepine therapy, the physician should:

establish a treatment agreement;









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order random urine drug testing (rUDT) and/or random pill counts at least annually if the patient is an adult;

counsel the patient appropriately regarding any ongoing workplace safety concerns related to the use of long-term opioid treatment, outlining work restrictions and limitations as needed;

reassess the patient at least every three months to: o ensure the medication is improving function and assess any side effects the patient

may be experiencing;

o determine if the patient may be developing tolerance;

o monitor closely for signs a) the patient is not taking the medication in the dose or by the route prescribed; and/or b) individuals other than the patient may be using the medication. These include: The patient requests early refills, claims to lose the medication or provides

excuses for why additional medication is needed;

PIN/Netcare review reveals the patient is multi-doctoring to obtain additional medication;

An alternate person requests the prescription from the physician when the patient is capable of attending themselves;

Another healthcare professional reports aberrant behaviour, such as a pharmacist reporting the medication is being picked up by individuals other than the patient for no justifiable reason; and

Consider a gradual taper, if clinically appropriate.

http://www.cpsa.ca/wp-content/uploads/2016/08/Clinical-Toolkit_BDZ_Nov_2016.pdf?x91570





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Example Scenarios The following scenarios illustrate how the standard would apply in various situations.

Scenario 1:

An anesthesiologist orders a single dose of benzodiazepine as a premedication for a surgical patient. Is it necessary to check the patient’s medication profile prior to writing the order?

Given that only a single dose of medication is being prescribed and the medication will be administered by a regulated healthcare provider in a supervised setting, the risks of substance-related harm to the patient or diversion to others is small. The value of checking the patient’s previous dispensing history may be limited; however, the anesthesiologist should be aware of the patient’s current medication history to ensure there are no contra-indications or potential drug interactions.

Scenario 2:

A neurologist prescribes clobazam for a patient with epilepsy. Prior to initiating the prescription several years ago, the neurologist obtained a thorough history including a detailed substance use assessment. The patient is stable and has been attending the neurologist semi-annually for follow up. Is it necessary to see the patient every three months?

Clobazam is a benzodiazepine and, as such, has the potential to cause substance-use disorder or substance-related harm, albeit less than other drugs within this class. Ideally, the neurologist should collaborate with the patient’s family physician to ensure the patient is followed up on a regular basis in accordance with CPSA’s advice. If there is sufficient information to justify not assessing the patient more frequently, the neurologist should ensure the justification is adequately documented in the patient’s record.

Scenario 3:

A physician accepts a patient from a retired colleague. The patient has been prescribed 2000 mg morphine equivalents a day for years. The physician believes the steps outlined in CPSA’s standard of practice are unnecessary because the patient is stable and the physician is only continuing the treatment.





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This is a high-risk scenario for both the patient and the public. Evidence confirms the risk of overdose and death increases at this dosage. Furthermore, the physician must maintain a high index of suspicion for the development of a substance use disorder and/or diversion of the medication to others; checking PIN/Netcare is essential to ensure the patient is not receiving additional medication from other providers. The physician should familiarize themselves with current opioid treatment guidelines and should also follow the steps outlined in CPSA’s standard of practice and this advice document.

Resources Prescriber Checklist CPSA Physician Prescribing Practices

Assessing Risk of Substance Use Disorders

The Drug Abuse Screening Test (DAST) Opioid Risk Tool CAGE Questionnaire NIDA Quick Screen Alcohol Use Disorders Identification Test (AUDIT) Tobacco, Alcohol, Prescription medication, and other Substance use Tool (TAPS)

Benzodiazepine Prescribing

Clinical Guidelines

Canadian clinical practice guidelines for the management of anxiety, post-traumatic stress and obsessive compulsive disorders

TOP Adult Insomnia Summary (for access to the full guidelines, visit the TOP website) Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice

for insomnia, agitation or delirium (American Geriatrics Society)

http://www.cpsa.ca/physician-prescribing-practices/

http://www.drtepp.com/pdf/substance_abuse.pdf

http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b02.html

http://nationalpaincentre.mcmaster.ca/documents/cage_questionnaire.pdf

https://www.drugabuse.gov/nmassist/step/0

http://auditscreen.org/

https://www.drugabuse.gov/taps/#/

http://www.ncbi.nlm.nih.gov/pubmed/25081580

http://www.ncbi.nlm.nih.gov/pubmed/25081580

http://www.cpsa.ca/wp-content/uploads/2016/06/Adult-Insomnia-Summary.pdf?3bed90&x91570

http://www.topalbertadoctors.org/cpgs/8640793

http://www.choosingwisely.org/clinician-lists/american-geriatrics-society-benzodiazepines-sedative-hypnotics-for-insomnia-in-older-adults/

http://www.choosingwisely.org/clinician-lists/american-geriatrics-society-benzodiazepines-sedative-hypnotics-for-insomnia-in-older-adults/





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Training Resources

Hone your skills: Are you an effective de-prescriber? Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies

Summary Toolkits

Clinical Toolkit: Use and Taper Choosing Wisely Canada Implementation Toolkit: Less Sedatives for Your Older

Relatives

Practice Supports

CBT-I Electronic Resources Patient Hand-Out Benzodiazepine Discontinuation Letter Template EMPOWER Benzodiazepine De-Prescribing Brochure

Opioid Prescribing and Pain Management

CADTH Evidence Bundles

Pain treatment, including non-pharmacological Opioids

Clinical Guidelines

Canadian Guideline for Opioids for Chronic Non-Cancer Pain (2017) – full guideline o Poster summary (English) o Poster summary (French)

CDC Guidelines for Prescribing Opioids for Chronic Pain (U.S.) – full guideline o Fact sheet o Summary of recommendations

Summary Toolkits

Opioid prescribing for chronic non-cancer pain: suggestions summary (CMPA)

http://www.choosingwiselycanada.org/webinars/hone-your-skills-are-you-an-effective-deprescriber-tackling-sedative-hypnotic-drugs-in-older-adults/

http://www.mayoclinicproceedings.org/article/S0025-6196(16)30509-2/fulltext

http://www.cpsa.ca/wp-content/uploads/2016/08/Clinical-Toolkit_BDZ_Nov_2016.pdf?x91570

http://www.choosingwiselycanada.org/in-action/toolkits/less-sedatives-for-your-older-relatives/

http://www.choosingwiselycanada.org/in-action/toolkits/less-sedatives-for-your-older-relatives/

http://www.cpsa.ca/wp-content/uploads/2016/08/CBTi_12122016.docx?x91570

http://www.cpsa.ca/wp-content/uploads/2016/08/Benzodiazepine-Discontinuation-Letter-v3.0.docx?x91570

http://www.criugm.qc.ca/fichier/pdf/BENZOeng.pdf

https://www.cadth.ca/evidence-bundles/opioid-evidence-bundle/browse-category#pain-treatment

https://www.cadth.ca/evidence-bundles/opioid-evidence-bundle/browse-category#pain-treatment


http://www.cpsa.ca/wp-content/uploads/2017/05/CMA_Opioid-poster_EN_HR1.pdf

http://www.cpsa.ca/wp-content/uploads/2017/05/CMA_Opioid-poster_FR_HR2.pdf



http://www.cpsa.ca/wp-content/uploads/2016/12/CMPA_opioid_Rx_non-cancer_pain.pdf?x91570&x91570





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Safer Decisions Save Lives: Key Opioid Prescribing Messages for Community Practitioners (ISMP)

Checklist for Prescribing Opioids for Chronic Pain (CDC) Tapering Opioids for Chronic Pain (CDC) Non-opioid Treatments for Chronic Pain (CDC) Clinical Toolkit: Urine Drug Screening Clinical Toolkit: Meperidine (Demerol®): A Relic Misfit for Chronic Pain

Practice Supports

Opioid Manager (for availability in EMR platforms click here) How to use the Opioid Manager (McMaster University)

Opioid Medication Treatment Agreement Template My Opioid Manager Book (for patients) by Dr. Furlan and Amy Robidas Opioid Manager for Prescribers (iTunes) Opioid Tool for Prescribers (iTunes) Opioid Overdose Prevention for Patients and Caregivers (iTunes) Opioid Pain Medicines- Information for Patients and Families (ISMP) Video Resources for Patient Education – click ‘Pain’ tab (My Health Alberta)

Training Resources

Pathways to Safer Opioid Use Module (US) Take Home Naloxone Program (Alberta Health Services) Opioid Analgesics: Risky Drugs, Not Risky Patients Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of

Chronic Pain Pharmacotherapy of Chronic Pain: A review

Opioid Agonist Treatment

CAMH Opioid Dependence Treatment Core Course (Alberta Version) Tapering Opioids for Chronic Pain (CDC) Non-opioid Treatments for Chronic Pain (CDC) Methadone Program

https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-08-OpioidPrescribing.pdf

https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-08-OpioidPrescribing.pdf

http://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf

http://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

http://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf

http://www.cpsa.ca/wp-content/uploads/2016/08/Clinical-Toolkit-Urine-Drug-Screening-v2.pdf?x91570

http://www.cpsa.ca/wp-content/uploads/2016/08/Clinical-Toolkit-Mepridine-A-Relic-Misfit-for-Chronic-Pain.docx.pdf?x91570

http://www.cpsa.ca/wp-content/uploads/2016/04/OpioidManager.pdf?x91570

http://nationalpaincentre.mcmaster.ca/opioidmanager/emr_platforms.html

https://www.youtube.com/watch?v=BpS4QzDPIa8


http://www.opioidmanager.com/uploads/3/4/3/2/3432072/myom_book_final.pdf

https://itunes.apple.com/us/app/opioid-manager/id527601780?mt=8

https://itunes.apple.com/us/app/opioid-tool/id827561557?mt=8

https://itunes.apple.com/us/app/opioid-overdose-prevention/id1041432203?mt=8

https://www.ismp-canada.org/download/opioid-handout-1page.pdf

https://myhealth.alberta.ca/health/Pages/HealthVideoPlayer.aspx

https://health.gov/hcq/training-pathways.asp

http://www.albertahealthservices.ca/info/Page13663.aspx

http://cpsa.ca/wp-content/uploads/2015/07/opioid-analgesics.pdf?x91570

http://cpsa.ca/wp-content/uploads/2015/07/Universal-Precautions.pdf?x91570

http://cpsa.ca/wp-content/uploads/2015/07/Universal-Precautions.pdf?x91570

http://cpsa.ca/wp-content/uploads/2015/07/Pharmacotherapy_of_chronic_pain_-_a_review_Lynch_2006.pdf?x91570

https://cumming.ucalgary.ca/cme/programs/camh-odt-alberta-version

http://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

http://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf

http://cpsa.ca/continuing-competency/methadone-program/





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Buprenorphine Prescribing Opioid Dependence Treatment Clinics in Alberta

RELATED STANDARDS OF PRACTICE

Code of Ethics & Professionalism

Establishing the Physician-Patient Relationship

Informed Consent

Patient Record Content

Prescribing: Administration


Safe Prescribing for Opioid Use Disorder

COMPANION RESOURCES

Advice to the Profession documents: o Informed Consent for Adults o Prescribing: Administration o Safe Prescribing for Opioid Use Disorder

http://cpsa.ca/?p=5217

http://cpsa.ca/physician-prescribing-practices/methadone-program/methadone-clinics-alberta/

https://policybase.cma.ca/documents/policypdf/PD19-03.pdf

http://www.cpsa.ca/standardspractice/establishing-physician-patient-relationship/



http://www.cpsa.ca/standardspractice/prescribing/

http://www.cpsa.ca/standardspractice/prescribing-drugs-misuse-diversion/

http://www.cpsa.ca/standardspractice/prescribing-drugs-misuse-diversion/

http://www.cpsa.ca/standardspractice/safe-prescribing-opioid-use-disorder/

http://www.cpsa.ca/wp-content/uploads/2016/02/AP_Informed-Consent-for-Adults.pdf

http://www.cpsa.ca/wp-content/uploads/2014/04/AP_Prescribing-Administration.pdf?x91570

http://www.cpsa.ca/wp-content/uploads/2019/03/AP_Safe-Prescribing-1.pdf





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Appendix A: General Medications List Any medication with a perceived potential for substance-use disorders or substance-related harm falls within the scope of this standard, which includes but is not limited to opioids, benzodiazepines, sedatives and stimulants.

Use this list as a general guide:

Alfentanil Amphetamines Benzodiazepines Buprenorphine Butalbital Butorphanol Cannabidiol Cocaine Codeine Dextro-amphetamine –

immediate release preparation

Dextropropoxyphene Fentanyl Hydrocodone Hydromorphone Ketamine Marijuana Meperidine Methadone Methylphenidate Morphine

Nabilone Nalbuphine Normethadone Oxycodone Oxymorphone Pentazocine Sodium Oxybate Sufentanil Tapentadol Testosterone Tetrahydrocannabinol Tramadol Zopiclone Zolpidem Zaleplon





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Appendix B: Prescriber Checklist Use this checklist when prescribing drugs associated with substance use disorders or substance-related harm to ensure all precautions and requirements have been met.

All prescriptions:

Documented rationale to justify prescribing – occurs at every assessment/reassessment

During initial assessment, including accepting transfer of care from another healthcare provider:

Discussed other pharmacological and non-pharmacological options with patient

Discussed common and potentially serious side-effects of the medication with patient

Discussed probability that the medication will improve the patient’s health

Discussed probability that the medication will improve the patient’s function

When issuing a prescription, at initiation and at minimum three month intervals for any of the applicable medications, including opioids:

Reviewed patient medication history from Pharmaceutical Information Network (PIN) /Netcare or alternative independent source (e.g., Triplicate Prescription Program, a pharmacist)

PIN/Netcare/alternate source not accessible, prescribed minimum amount of medication for interim purpose

When prescribing any of the included medications long-term:

Patient medication history reviewed periodically, at minimum every three months

When prescribing opioids for long-term therapy for chronic pain (except for active cancer, palliative and end-of-life care):

Established goals for pain and function





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Measured and documented goals for pain and function initially AND at each reassessment

Evaluated and documented risk factors for opioid-related harms

Incorporated strategies to mitigate the risks (e.g., treatment agreement)

Prescribed lowest effective dose and dose does not exceed CPSA Council-endorsed opioid prescribing guidelines

If prescribed dose exceeds CPSA Council-endorsed opioid prescribing guidelines, documented additional information with specific justification

Reassessed Long-term Opioid Therapy (LTOT) by measuring against goals to support need for continuation of therapy within four weeks of initiating LTOT and then at least every three months

Documented all reassessments of measured benefit in the comparison to risks from continued therapy

LTOT continued only as measurable clinical improvement in function and pain surpass the risks of continued opioid therapy

LTOT no longer delivering measurable clinical improvement in function and pain relative to the risks of continued opioid therapy; LTOT discontinued or this prescribing is part of a LTOT discontinuation plan




advice to the profession prescribing: drugs associated

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